Golden Merced Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Merced, California.
- Location
- 3170 M Street, Merced, California 95340
- CMS Provider Number
- 055988
- Inspections on file
- 37
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Golden Merced Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities was readmitted from the hospital with documented pressure wounds on the sacrum and right heel. The admitting nurse only identified the right heel wound, failing to assess, document, or communicate the sacral wound as indicated in the hospital discharge summary. As a result, the sacral wound was not evaluated or treated, and wound care staff were not informed, contrary to facility policy requiring comprehensive admission assessments and wound documentation.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report highlights that the environment did not meet required safety standards.
A resident with severe cognitive impairment and a known elopement risk exited the facility undetected, despite wearing a functioning security bracelet. Staff response to the activated door alarm was delayed, and the initial search failed to locate the resident, who was later found in a nearby parking lot and returned without injury. This incident reflects a failure to provide adequate supervision and prevent accidents.
A resident with severe cognitive impairment and a history of stroke was admitted without an elopement risk assessment, contrary to facility policy. This omission led to the resident leaving the facility unsupervised in a wheelchair and being found by an LPN off facility grounds. The required assessment was not completed until over a month after admission.
Fifteen unsecured sliding glass doors in resident rooms allowed a resident with dementia and a history of wandering to elope twice in one day, with the second incident resulting in the resident being found 0.6 miles away in a confused state. The facility lacked alarms or monitoring systems on these doors and exterior gates, and staff confirmed that both residents and unknown visitors could enter or exit without detection.
The facility failed to meet residents' food preferences by removing the microwave and instructing staff not to warm up food, leading to resident frustration. Two cognitively intact residents, with conditions such as heart failure and diabetes, expressed dissatisfaction as they could no longer enjoy their food at acceptable temperatures. The administration cited safety concerns and lack of staff training as reasons for the change, but no alternative solution was provided.
The facility failed to implement baseline care plans within 48 hours for three residents upon admission, as required by policy. Two residents with respiratory conditions and a resident with a PICC line for antibiotic therapy did not have their care needs documented, potentially impacting their care. Interviews with staff confirmed the absence of these plans, which are crucial for guiding care and ensuring residents' health needs are met.
The facility failed to develop comprehensive care plans for four residents, leading to potential health risks. A resident had incomplete care plans for anxiety and antipsychotic medications, while another lacked plans for psychotropic and anti-anxiety medications. Two residents did not have care plans for critical medications and treatments, including anticoagulants, insulin, and hemodialysis. The absence of these plans hindered proper monitoring and care, as acknowledged by the facility's staff.
The facility failed to adhere to physician orders and medication protocols for three residents. A resident with pleural effusion did not receive continuous oxygen as prescribed. Another resident had an incomplete Lidocaine Patch order, leading to potential ineffective pain control. A third resident, at high risk for pressure ulcers, did not have the prescribed Pressure Reduction mattress, and their refusal was not documented. These deficiencies highlight lapses in following facility policies.
The facility failed to properly store medications, with issues including lack of open dates on insulin pens, expired medications, and improper storage of opened bottles. These deficiencies were observed in multiple medication carts and a storage room, posing risks of decreased medication potency and potential medication errors.
The facility failed to store and monitor food according to professional standards, risking foodborne illness. A freezer contained unlabeled frozen chicken, and lacked a thermometer to monitor temperature. During lunch service, the cook did not check the temperature of meat loaf and au gratin potatoes before serving, violating food safety protocols.
The facility failed to maintain a sanitary environment, leading to potential infection risks. A resident's graduated cylinder was found soiled and improperly stored, while another's nasal cannula was on the floor, and nebulizer equipment was stored incorrectly. An expired humidifier solution posed a risk of bacterial growth, and an LPN failed to wear PPE during a dressing change. Additionally, money was improperly stored in a medication cart, risking contamination.
The facility failed to maintain the dignity and privacy of two residents. One resident's urinary catheter bag was left uncovered, visible to others, compromising their privacy. Another resident was subjected to a 20-minute timer for morning ADL care, making them feel rushed and singled out. Both actions violated the facility's policy on dignity and respect.
A resident experienced a major improvement in cognitive function, as indicated by a BIMS score change from 99 to 15, but the facility failed to implement a significant change of condition. The interdisciplinary team did not conduct a formal meeting to address the change, and the plan of care was not updated. The facility's policy requires notification of such changes within 24 hours, which was not followed.
Two residents in a facility experienced deficiencies in IV fluid administration and central line care due to inadequate training and lack of proper procedures. One resident's PICC line was improperly removed, and another's midline dressing change was not performed with sterile technique. Staff interviews revealed insufficient training and reliance on past experiences rather than formal competency validation.
A resident with a history of Paranoid Personality Disorder repeatedly took unauthorized photos and videos of other residents and staff using a smartphone, despite staff awareness and attempts to redirect her. Multiple staff and residents confirmed the ongoing behavior, which included photographing individuals and sensitive information, resulting in violations of resident privacy.
A resident with a high risk of falls did not have a Dycem non-skid mat placed on her wheelchair, despite multiple recommendations from the IDT and documentation in her care plan. The resident, who had conditions such as dementia and muscle weakness, experienced several unwitnessed falls. Observations and staff interviews confirmed the absence of the Dycem mat, highlighting a failure to adhere to the facility's fall risk management policy.
The facility failed to implement fall prevention measures for two residents, including providing non-skid socks and transfer bars as ordered by physicians. Additionally, staff were unable to accurately describe key interventions of the fall prevention program, indicating a lack of understanding of the 4 P's: Pain, Personal belongings, Personal care, and Positioning.
A resident's repeated requests for fried or poached eggs were not honored, despite being cognitively intact and on a regular diet. The facility's policy on pasteurized egg products was initially misinterpreted, leading to the resident being consistently served scrambled eggs instead.
The facility failed to ensure that the designated interdisciplinary team member obtained the hospice plan of care for a resident admitted to hospice services. Despite the resident's significant medical history and hospice admission, the hospice plan of care was not documented in the resident's EMR until after the deficiency was identified.
Failure to Identify and Document All Wounds on Readmission
Penalty
Summary
The facility failed to accurately identify and document all wounds present on a resident's readmission from the hospital. Upon review of the resident's hospital discharge summary and history and physical, it was indicated that the resident had two pressure wounds: one on the sacrum and one on the right heel. However, during the facility's admission process, only the right heel wound was identified and documented by the admitting nurse. The sacral wound, which was noted in the hospital records as infected, was not assessed, documented, or communicated to the wound care provider upon the resident's return. Interviews with facility staff, including the DON, LVNs, and the wound care NP, confirmed that the admitting nurse did not complete a thorough head-to-toe skin assessment or review the hospital discharge summary in detail. As a result, the sacral wound was not recognized, and no treatment orders were initiated for it. The wound care nurse and NP were not made aware of the sacral wound, and the resident was not included in wound care rounds or assessments for that area. The facility's policies required a comprehensive admission evaluation, including documentation and measurement of all wounds, and obtaining treatment orders, but these procedures were not followed in this instance. The resident involved had multiple complex medical diagnoses, including type 2 diabetes, anemia, chronic atrial fibrillation, chronic kidney disease, heart failure, and pancytopenia, all of which increased the risk for skin breakdown and infection. Despite being at high risk and returning from the hospital with documented wounds, the facility's failure to identify and address all wounds led to a lack of assessment and treatment for the sacral wound following readmission.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions by staff or details about the residents involved are not provided in the report.
Resident Elopement Due to Delayed Staff Response to Security Alarm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known history of elopement risk exited the facility without staff knowledge. The resident was last seen ambulating in a hallway and was later found approximately 350 feet away in a nearby fast-food restaurant parking lot. The facility had an electronic security bracelet system in place for the resident, which was functioning at the time, and a door alarm was activated. However, staff response to the alarm was delayed, with the responding LVN arriving at the door within five minutes, searching the area, but failing to locate the resident. The resident was ultimately found and returned to the facility by staff after being identified by a former employee outside the premises. The resident's records indicated a history of impaired cognition and previous elopement risk, with interventions in place such as a security bracelet. Despite these measures, the staff did not respond to the door alarm within the facility's expected timeframe of one minute or less, and the initial search did not result in locating the resident. The facility's policy defined elopement as a resident exiting without staff knowledge, which occurred in this incident. No injuries were noted upon the resident's return, but the event demonstrated a failure to provide adequate supervision and prevent accidents as required.
Failure to Assess Elopement Risk at Admission Resulting in Resident Elopement
Penalty
Summary
The facility failed to assess a resident for elopement risk factors upon admission, as required by facility policy. The resident, who had a history of cerebral infarction, impaired cognition, and alcohol abuse, was admitted without a completed Nursing Admission Evaluation to determine elopement risk. The Minimum Data Sheet indicated the resident had severely impaired cognition, and the facility's policy required that an elopement risk assessment be completed at admission. However, the assessment was not performed until 41 days after admission. As a result of this omission, the resident was able to leave the facility unsupervised in a wheelchair and was found by a staff member approximately 1,000 feet from the facility. The staff member returned the resident to the facility, and a Wander Guard was applied afterward. Interviews with staff confirmed that the elopement risk assessment was not completed as required, and the administrator acknowledged the failure to follow policy regarding timely assessment at admission.
Unsecured Sliding Glass Doors Lead to Resident Elopement
Penalty
Summary
The facility failed to ensure the safety and security of its residents by not securing 15 sliding glass doors located in resident rooms, which provided direct access to the exterior of the building. These doors were not equipped with alarms or any system to alert staff when opened, and the gates leading from the exterior walkways to the parking lot and city streets were also unsecured. Maintenance staff confirmed that there was no system in place to monitor these exits, and the administrator acknowledged that ambulatory residents could leave or unknown visitors could enter the facility without staff knowledge through these doors. A resident with diagnoses including dementia, psychosis, and disorientation, and who was identified as an elopement risk, was able to leave the facility twice in one day through one of these unsecured sliding glass doors. On the second occasion, the resident was found by staff 0.6 miles from the facility in a confused state after having crossed multiple lanes of traffic. Progress notes and interviews with staff confirmed that the resident left through her room's sliding glass door, which did not have an alarm, and that the exterior gates were also not locked. The facility's own policy required evaluation and implementation of appropriate interventions for residents at risk of wandering or elopement, but records and interviews indicated that these measures were not in place for the 15 sliding glass doors. The facility assessment documented that the facility serves residents with impaired cognition, memory loss, and dementia, further underscoring the vulnerability of the population affected by the lack of secure exits.
Facility Fails to Accommodate Residents' Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of residents by not providing a means to warm up food brought in from outside. This issue arose when the facility removed the microwave from the resident food storage area and instructed staff not to warm up food for residents. This decision led to frustration among residents who were unable to enjoy their food at acceptable temperatures for palatability. Two residents, both cognitively intact, expressed their dissatisfaction with the new policy. One resident, who had been admitted with heart failure, diabetes mellitus type II, and kidney failure, stated that he relied on food brought in for evening snacks and was frustrated by the inability to have it warmed. Another resident, admitted with heart failure, supraventricular tachycardia, and morbid obesity, also expressed that the facility was violating her rights by not heating up the food her family brought her. The facility's administration cited safety concerns and lack of staff training as reasons for the removal of the microwave. The Director of Staff Development mentioned that CNAs were not equipped with thermometers or trained to properly heat food, and the Administrator noted the absence of a temperature log. Despite several residents' complaints, the facility had not provided an alternative solution to heat up food for residents.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans for three residents within 48 hours of their admission, as required by their policy. Residents 221 and 222, who were admitted with respiratory conditions such as pleural effusion, pneumonia, and COPD, did not have their baseline care plans completed. This omission meant that their respiratory care needs, including the use of oxygen, were not properly documented or planned for, potentially impacting their care. Interviews with the LVN and MDSRN revealed that the responsibility for creating these care plans lay with the nurses, and the absence of these plans could hinder the staff's ability to provide appropriate care. Resident 421, admitted with a PICC line for antibiotic therapy, also did not have a baseline care plan implemented within the required timeframe. The absence of a care plan for the PICC line meant that specific care instructions and monitoring strategies were not documented, which could have led to a decline in the resident's health. Interviews with the DON and RN confirmed that a care plan should have been in place to guide the care and ensure the resident's health needs were met. The facility's policy on baseline care plans, dated March 2022, mandates that a plan be developed within 48 hours of admission to address immediate health and safety needs. This policy was not adhered to for the three residents, as evidenced by the lack of documented care plans for their specific medical conditions and treatments. The failure to implement these plans could have compromised the quality of care provided to the residents, as it left staff without clear guidance on how to meet their immediate health needs.
Incomplete Care Plans for Residents' Medications and Treatments
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential risks for their health and well-being. Resident 71 had an incomplete care plan for anxiety medication and lacked care plans for Sertraline and Olanzapine, which are crucial for managing their mental health conditions, including bipolar disorder and PTSD. The absence of specific goals and monitoring parameters in the care plan for anxiety medication was acknowledged by LVN 3, who emphasized the importance of having a specific number of episodes to observe to evaluate the medication's effectiveness. Resident 72 did not have individualized care plans for Quetiapine, Buspirone, and Lorazepam, despite these medications being prescribed to manage their bipolar disorder and anxiety. The care plans for these medications were created after the medications were ordered, which LVN 3 noted should have been done concurrently to ensure proper monitoring and effectiveness. The Director of Nursing (DON) confirmed the oversight and stressed the importance of comprehensive care plans for short-term residents to facilitate their recovery and return to baseline prior to discharge. Resident 223 lacked care plans for Apaxiban, insulin, diabetic care, and hemodialysis, which are essential for managing their complex medical conditions, including Type II Diabetes and End Stage Renal Disease. The absence of these care plans posed a risk of inadequate monitoring and care. Similarly, Resident 47 did not have a care plan for apixaban, an anticoagulant, which is critical for preventing blood clots and managing their heart condition. The DON and MDS Nurse acknowledged the importance of timely and complete documentation to ensure resident-centered care.
Non-Compliance with Physician Orders and Medication Protocols
Penalty
Summary
The facility failed to meet professional standards of quality for three residents due to non-compliance with physician orders and medication administration protocols. Resident 221, who was admitted with a primary diagnosis of pleural effusion, did not receive the prescribed continuous oxygen therapy. During an observation, it was noted that the resident's oxygen concentrator was turned off, and the nasal cannula was stored in a bag. The Licensed Vocational Nurse (LVN) confirmed that the resident required continuous oxygen delivery, and the Director of Nursing (DON) acknowledged that the resident might have received an inappropriate amount of oxygen due to the lack of adherence to the physician's order. Resident 321 experienced a deficiency in medication administration. The resident had an order for a Lidocaine Patch to be applied for pain relief, but the order did not specify the exact location for application. During an observation, the LVN placed the patch on the resident's right shoulder, although the resident expressed pain in a different area. The Pharmacy Consultant and the DON both confirmed that the medication order was incomplete, lacking specific instructions on where to apply the patch, which could lead to ineffective pain control. Resident 4, who was at high risk for pressure ulcers due to paraplegia and other conditions, did not have the prescribed Pressure Reduction mattress in use. The resident was observed lying on a regular mattress, and the LVN stated that the resident had refused the specialized mattress, although this refusal was not documented. The DON confirmed that the physician should have been informed of the refusal, and the lack of documentation and communication could result in the resident's wounds worsening. The facility's policies on medication orders and pressure injury prevention were not followed, contributing to these deficiencies.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to properly store medications in several areas, including three medication carts and one medication storage room. In the South one medication cart, an unopened insulin pen intended for refrigeration was found not stored as recommended, and multiple medications for several residents lacked open dates. This oversight could lead to the use of medications past their effective date, potentially compromising their therapeutic effectiveness. In the South two medication cart, six insulin pens for various residents were found without open dates, and expired medications were present. Additionally, several eye drop bottles and respiratory medications lacked open dates. The presence of expired and improperly labeled medications increases the risk of medication errors, as noted by the staff during interviews. The North one medication cart contained discontinued medication and multi-dose medications without open dates. An expired over-the-counter medication was also found. In the North medication storage room, expired medications, incorrectly labeled expiration dates, and opened bottles stored inappropriately were observed. These deficiencies highlight the potential for decreased medication potency and the risk of administering expired or discontinued medications, as emphasized by the staff and pharmacy consultant during interviews.
Food Safety Deficiencies in Storage and Temperature Monitoring
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In one of the freezers, a clear plastic bag containing what appeared to be frozen chicken was found without any labels or closure device. The District Manager of the kitchen acknowledged that the meat should have been stored in a labeled, airtight container to ensure food freshness and safety. The absence of proper labeling and storage could lead to serving expired foods, increasing the risk of foodborne illness among residents. Additionally, the facility did not have a thermometer in the chest freezer to monitor the internal temperature, which is crucial for preventing bacterial growth. The Dietary Aid confirmed that a thermometer should be present and checked daily. Furthermore, during a lunch tray line service, the cook failed to take the temperature of the meat loaf and au gratin potatoes before serving, which is a necessary step to ensure food safety. The facility's policy and procedure, as well as the California Code of Regulations, emphasize the importance of maintaining specific temperatures for food storage and service to prevent contamination and ensure the safety of the food served to residents.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment, leading to potential cross-contamination and infection risks for several residents. Resident 25's graduated cylinder, used for measuring urine output, was found visibly soiled, uncovered, and unlabeled on top of a shared toilet. This oversight was acknowledged by the LVN, Infection Preventionist (IP), Assistant Director of Nursing (ADON), and Director of Nursing (DON), all of whom recognized the potential for cross-contamination and infection due to improper storage and lack of cleaning. Resident 20's nasal cannula was observed touching the ground, and nebulizer equipment was improperly stored in the same bag as the nasal cannula. The IP, Central Supply Clerk (CSC), ADON, and DON all noted that this improper storage and handling could lead to cross-contamination and infection, as the nasal cannula delivers oxygen directly to the resident's mucosal membrane. The CSC admitted responsibility for replacing and properly storing the equipment, which was not done in this case. Resident 12's humidifier bottle and solution were found expired and not replaced, posing a risk of bacterial growth and respiratory infection. The IP, CSC, ADON, and DON all acknowledged the oversight, with the CSC admitting failure to change the humidifier bottle and solution as required. Additionally, LVN 5 failed to wear appropriate PPE while performing a dressing change for Resident 371, increasing the risk of infection. Lastly, money was improperly stored in the South one medication cart, which could lead to contamination of medications. The IP, Pharmacy Consultant (PC), and DON were unaware of this practice and recognized it as an infection control issue.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and privacy of Resident 25 by not covering their urinary catheter bag with a dignity bag. This oversight was observed during a room visit, where the catheter bag was visible to other residents and visitors, potentially compromising the resident's dignity and privacy. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) both acknowledged that the catheter bag should have been covered, as per the facility's policy and procedure on dignity, which emphasizes the protection of resident privacy and confidentiality. Resident 47 experienced a violation of their right to dignity when the facility implemented a 20-minute time limit for morning Activities of Daily Living (ADL) care using a timer. This practice made the resident feel rushed and singled out, as no other resident was subjected to such a time constraint. The resident's family member expressed frustration over this practice, and the Certified Nursing Assistant (CNA) confirmed the use of the timer to limit the time spent on morning care. The DON admitted that using a timer was an extreme first step and acknowledged that it could make the resident feel singled out. Both deficiencies highlight the facility's failure to adhere to its policy on treating residents with dignity and respect. The policy explicitly prohibits demeaning practices and emphasizes the importance of maintaining resident privacy and allowing residents to exercise their rights without discrimination or reprisal. The facility's actions in both cases were inconsistent with these standards, leading to the reported deficiencies.
Failure to Implement Significant Change of Condition for Resident
Penalty
Summary
The facility failed to implement a significant change of condition for a resident who experienced a major improvement in mentation. The resident, who was initially unable to make her needs known and was not her own responsible party, showed a significant improvement in cognitive function as indicated by a BIMS score change from 99 to 15. Despite this improvement, no significant change of condition was completed, and the plan of care was not updated to reflect the change in mentation. The deficiency was identified through interviews and record reviews, which revealed that the facility's interdisciplinary team did not conduct a formal meeting to address the resident's change in condition. The MDS Coordinator and the Social Services Director acknowledged the oversight, noting that the change in BIMS score should have triggered a change of condition. The facility's policy requires notification of a significant change in a resident's condition within 24 hours, but this was not adhered to in this case.
Deficient IV Fluid Administration and Central Line Care
Penalty
Summary
The facility failed to administer parenteral fluids in accordance with professional standards of practice for two residents, leading to potential adverse outcomes. Resident 421 was admitted with a PICC line for IV antibiotics, but the facility lacked an approved policy and procedure for PICC line care. Registered Nurses and the Assistant Director of Nursing were not trained in PICC line care, resulting in improper removal of the PICC line by RN 1, who used a band-aid instead of an occlusive dressing and did not instruct the resident to lay flat post-removal. Resident 422 was admitted with a midline for IV antibiotics, but the facility also lacked an approved policy and procedure for midline care. During a dressing change, the Assistant Director of Nursing failed to follow sterile technique, allowing the midline to touch non-sterile linens and not ensuring the resident wore a mask. The midline was not in proper placement and had to be removed, indicating a lack of proper training and competency in central line management. Interviews with facility staff revealed that nurses were insufficiently trained in central line care and management, relying on past job experiences rather than formal training. The Director of Nursing acknowledged the need for competency in central line management and the potential harm from inadequate training, including complications such as infections or air embolisms. The facility's policies and procedures were not adequately followed, and there was a lack of documented training and competency validation for staff handling central lines.
Failure to Protect Resident Privacy Due to Unauthorized Photography
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records when a resident with a diagnosis of Paranoid Personality Disorder repeatedly took photographs and videos of other residents and staff without their consent. Multiple staff members, including the Social Services Director, Assistant Director of Nursing, and a Registered Nurse, observed the resident using her smartphone to take photos of residents, staff, hallways, nurses' stations, and even patient names and room numbers. Progress notes documented the resident's ongoing behavior, including verbal aggression and refusal to comply with redirection efforts. Other residents and staff confirmed that the resident frequently took photos and videos, sometimes following residents to their doorways to do so. One cognitively intact resident reported being followed and photographed against their wishes, and a Certified Nursing Assistant stated that the resident showed her the photos and videos taken of other residents. Despite staff attempts to redirect the resident and discussions with her about not taking pictures, the behavior persisted, resulting in the violation of an unknown number of residents' privacy rights.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident, identified as Resident 3, who was at risk for falls. Despite multiple recommendations from the Interdisciplinary Team (IDT) meetings following several unwitnessed falls, the facility did not place a Dycem non-skid mat on the resident's wheelchair. The resident's care plan, which was undated, indicated the need for a Dycem mat on the wheelchair as an intervention to mitigate fall risks. However, during observations and interviews conducted on November 22, 2024, it was noted that the Dycem mat was not present on the resident's wheelchair, contrary to the care plan and IDT recommendations. Resident 3 had a history of conditions that increased her fall risk, including anemia, muscle weakness, difficulty walking, abnormalities in gait and mobility, and dementia. The Minimum Data Sheet (MDS) assessment indicated that the resident had moderately impaired cognition and required substantial assistance for transfers. Despite these documented needs and the facility's policy on managing fall risks, the necessary intervention of placing a Dycem mat was not executed, as confirmed by staff interviews and record reviews.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement necessary physical interventions to mitigate fall risks for two residents as part of their fall prevention program. Resident 1, who was diagnosed with conditions such as dorsalgia, unspecified dementia, and osteoporosis, was identified as high fall risk. Despite a physician's order for non-skid socks as a fall prevention measure, Resident 1 was observed without them on multiple occasions. The resident had a history of falls, with nine incidents since admission, and was noted to be severely cognitively impaired. The facility's care plan and physician's orders clearly indicated the need for non-skid socks, yet these were not provided, as confirmed by a Certified Nursing Assistant who was unable to locate them. Resident 2, diagnosed with epilepsy, muscle weakness, and osteoporosis, was also at risk for falls. The resident's care plan and physician's orders specified the use of two transfer bars for assistance with bed mobility and transfers. However, during an observation, only one transfer bar was found on the resident's bed. This discrepancy was confirmed by a Licensed Vocational Nurse, who acknowledged that the resident's physician's orders were not being followed. The resident had previously expressed concerns about the lack of side rails, indicating a heightened awareness of her fall risk. Additionally, the facility staff demonstrated a lack of understanding of the fall prevention program's key interventions, specifically the 4 P's: Pain, Personal belongings, Personal care, and Positioning. Interviews with three staff members revealed that none could accurately describe all four components, which are crucial for effective fall prevention. The Director of Nursing acknowledged the expectation that staff should be aware of these interventions, yet the deficiency in staff knowledge persisted, potentially compromising resident safety.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, specifically the request for fried or poached eggs. The resident, who was cognitively intact and on a regular, fortified diet with thin liquids, repeatedly asked for fried or poached eggs but was consistently served scrambled eggs instead. The resident had communicated this preference to dietary staff and mentioned it during a resident council meeting, but the request was not accommodated. The facility's policy required the use of pasteurized egg products for soft-cooked egg items, which the Dietary Manager initially interpreted as a restriction against serving fried or poached eggs. Upon review, the Dietary Manager acknowledged that the facility could accommodate the resident's preference for fried eggs by using shelled eggs. The Director of Nursing and the Administrator both stated that they expected staff to notify dietary and nursing staff of specific food requests to ensure residents' preferences were honored. Despite these expectations, the resident's request for fried or poached eggs was not fulfilled, leading to the deficiency noted in the report.
Failure to Obtain Hospice Plan of Care
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the hospice plan of care for Resident #27, who was admitted to hospice services. The facility's policy required the Director of Nursing (DON) to coordinate care and obtain the hospice plan of care, but the DON was unaware of this responsibility until informed by the Administrator. Interviews with various staff members, including Licensed Vocational Nurse (LVN) #1, Registered Nurse (RN) #2, RN #3, and the Medical Records Director (MRD), revealed that the hospice plan of care for Resident #27 was not documented in the resident's electronic medical record (EMR) until 05/01/2024, despite the resident being admitted to hospice on 04/03/2024. Resident #27 had a significant medical history, including stage four pressure ulcers, dementia, type two diabetes mellitus, and a history of malignant neoplasms. The resident's comprehensive care plan indicated hospice admission on 04/03/2024, but the hospice plan of care was not available in the EMR. The MRD received a packet of hospice records on 05/01/2024, but there was no prior documentation of the hospice plan of care. The DON and other staff members confirmed that the hospice plan of care should have been provided and maintained in the resident's EMR, but this was not done until after the deficiency was identified.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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